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Acute renal failure Algorithm Please review definition and pathophysiology Assess for the presence of major risk factors: Advancing age with CHF, DM HTN Pre-renal: Intra-renal Dehydration Acute tubular necrosis (ATN) Hypovolemia Autoimmune kidney disease; SLE. Sepsis scleroderma Hemorrhage Diabetic nephropathy Burns Hypertensive nephropathy Trauma Infections Serious illness and surgery Hemolytic uremic syndrome Low cardiac output syndromes Nephrotoxins; contrast dye ITP YES NO Are Risk Factors Present? Initiate client education for Health Seeking Behaviors to identify: Screening urine for microalbinemia if compelling med history is present; HTN, DM, autoimmune disease, etc Don’t abuse alcohol or drugs especially OTC drugs that have a nephrotoxic profile Avoid long-term exposure to heavy metals, such as lead, as well as to solvents, fuels and other toxic substances. Ensure adequate hydration Use appropriate hygiene NO to reduce risk of infections Encourage routine disease screening and periodic physical exam according to risk profile Instruct client in s/s of risk factors to report Teach client s/s of acute renal failure to report Box 1 Negative Assess for s/s of ARF: DecreasedYES urine output; Nocturia Swelling/edema Weight gain s/s of fluid overload; CP, SOB hypotension, hypertension Are positive findings present? Initiate the plan of care for a Risk for Ineffective Therapeutic Regimen management: Stable, newly diagnosed? Potentially unstable? Follow plan of care for PC: ESRD Post-renal Obstructive uropathy; Ureteral, bladder outlet Prostate gland disorders Teach client about course and progression and the potential complication of ESRD if ARF is not corrected Explain diagnostic testing if indicated definition and interpretation of results; bloodwork such as creatinine, and calculation of GFR; urine testing such as creatinine clearance and microabumin, kidney radiographic procedures; IVP, KUB, renal ultrasound, CT scanning, biopsy Assist client in strategies to reduce modifiable risk factors Teach client strategies to protect kidney from injury, nephrotoxin avoidance (radio contrast agents, aminoglycosides, NSAIDs) and infection protection Instruct in use of medications for acute and chronic use; dopamine for decreased perfusion, ACE inhibitors for nephroprotection Review diet and hydration according to disease state, discuss lower protein, sodium and potassium as ESRD develops Review renal replacement therapies in the presence of ESRD or unresponsive ARF; indications and considerations such as hemodialysis, peritoneal dialysis and transplantation Patient teaching from box 1 Box 2 OUTCOMES/BENCHMARKS: Urine output > 30 ml/hr Creatinine and GFR WNL for age, no microalbuminuria No edema, weight gain, s/s of fluid overload such as DOE; SOB, 140>SBP> 100, 100>HR> 60 no dysrhythmia PC: ESRD ASSESS s/s of renal failure Decreased urine output; Nocturia Swelling/edema Weight gain s/s of fluid overload; CP, SOB hypotension, hypertension Assess for contributing factors: Pre-renal. Intra-renal and post renal DO Protect kidney from further harm Discontinue or adjust any medications that require adjustment for renal dosing Relieve obstructive uropathy Control autoimmune exacerbation Ensure adequate renal tissue perfusion Reversal of hypovolemia by rapid fluid infusion often is sufficient to treat many forms of ARF. Monitor for fluid overload Administer prescribed diuretics to promote urine output if indicated and dopamine agents by IV infusion to ensure renal perfusion as ordered and monitor effect Prevent electrolyte and acid base disturbances: Avoid agents that exacerbate hyperkalemia and hypernatremia Renal replacement therapy may be required Provide renal replacement therapy as ordered and monitor effectiveness Acute H/D, PD, and CVVHD MONITOR Monitor for hypo/hypertension, tachycardia, tachypnea, Monitor hourly I/O for urine output < 30 ml/hr Monitor for rising serum BUN & creatinine Monitor urine for presence of protein Monitor daily weights Monitor for contributing factors Monitor labs that indicate hematologic etiology; Hemoglobin, hematocrit and platelets Monitor labs indication low cardiac output syndrome; echocardiogram, chest x-ray, serum BNP Monitor lab/diagnostics for autoimmune etiology; complement, ESR Monitor lab/diagnostics for obstructive etiology; KUB, IVP Monitor for complications: Hyperkalemia, metabolic acidosis, uremia CALL Call for refractory creased urine output and hemodynamic instability Initiate ABC, shock management and call ready response t4eam and MD